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1 CANCERCARE CONNECT BOOKLET SERIES Treatment Update Ovarian Cancer

2 The CancerCare Connect Booklet Series offers up-to-date, easy-to-read information on the latest treatments, managing side effects and coping with cancer. To order free copies of this booklet, please use the online order form on our website, Founded in 1944, CancerCare is the leading national organization providing free, professional support services and information to help people manage the emotional, practical and financial challenges of cancer. Our comprehensive services include counseling and support groups over the phone, online and in person, educational workshops, publications and financial and co-payment assistance. All CancerCare services are provided by oncology social workers and world-leading cancer experts. CancerCare relies on the generosity of supporters to provide our services completely free of charge to anyone facing a cancer diagnosis. If you have found this resource helpful and wish to donate, please do so online at You may also mail a check, payable to CancerCare, to CancerCare, Attn: Donations, 275 Seventh Avenue, New York, NY Thank you. CancerCare National Office 275 Seventh Avenue New York, NY Toll-free HOPE (4673) Phone Fax Web The content of this booklet is independent, non-promotional and free of commercial influence and bias.

4 Thanks to a number of new treatments, more women with ovarian cancer are living longer after diagnosis. Each year, an estimated 22,000 women in the United States are diagnosed with ovarian cancer. This diagnosis affects the ovaries glands which produce the female reproductive cells (ova). The ovaries, each about the size of an almond, are located beside the uterus on each side of the lower abdomen. There are more than 30 types and subtypes of ovarian cancer. Most experts group ovarian cancers into three major categories, based on the type of cells from which they were formed: Epithelial tumors arise from cells that line or cover the ovaries. This is the most common category of ovarian cancer, accounting for approximately 90 percent of cases. Germ cell tumors originate from cells that are destined to form eggs within the ovaries. Sex cord-stromal cell tumors begin in the connective cells that hold the ovaries together and produce female hormones. Most women with ovarian cancer experience symptoms that are subtle, and can be associated with other medical conditions. Symptoms may include abdominal bloating or swelling, trouble eating or feeling full quickly, discomfort in the pelvic area, and a frequent need to urinate. 2

5 Stages of Ovarian Cancer To plan the best treatment, your doctor needs to know the stage of your cancer whether and how much it has spread to nearby tissues and organs. Since ovarian cancer is often discovered when it has already advanced, treatment usually begins with surgery, in which the surgeon removes as much of the cancer as possible. After surgery, samples of the tumor and tissues from the pelvis and abdomen are put under a microscope to stage the cancer. Stage 1: The cancer is found only in the ovary (or ovaries). Stage 2: The cancer has spread into other parts of the pelvis, such as the bladder or lower colon. Stage 3: The cancer has spread beyond the pelvis, into the lining of the abdomen or the lymph nodes, which are the small filtering stations that remove waste and fluids from tissues and organs and help fight infections in the body. Stage 4: The cancer has spread into more distant organs, such as the liver or lungs. To help determine the stage of the cancer, other tests may be performed, such as: CT scan, which combines X-ray images taken from different angles with computer processing to create cross-sectional images of organs and tissues. MRI, a technique that uses a magnetic field and radio waves to create detailed images of the organs and tissues within your body. PET scan, a functional imaging test that uses a radioactive drug to detect cancer. CANCERCARE CONNECT TREATMENT UPDATE: OVARIAN CANCER 3

6 Before surgery, a blood test may be performed to measure your levels of CA-125, a sugar-related protein found in the blood. Women with ovarian cancer often have high levels of this protein, but it is not the most reliable indicator that a tumor is present, as CA-125 can be absent when cancer is present, and levels can be high when no cancer exists. Still, doctors use CA-125 as a gauge, and blood tests to measure CA-125 may also be performed post-surgery and during subsequent treatment. Treatment Options Surgery Treatment for ovarian cancer usually begins with surgery, in which the surgeon removes as much of the cancer as possible. In many cases, a total hysterectomy (removal of the uterus and ovaries) is performed. Experts recommend that the surgery be performed by a gynecologic oncologist a specialist who has training and experience in treating and staging ovarian cancer. Gynecologic oncologists are also more likely than general surgeons and gynecologists to optimally debulk the cancer. Optimal debulking means that, after surgery, no visible tumor remains, or the size of the remaining tumor is less than one centimeter (less than half an inch). Suboptimal debulking is when more than one centimeter of tumor is left behind. Some decisions about future treatment are based on whether the surgery is optimal or suboptimal, so it s important information for you to know. 4

7 Chemotherapy After surgery, almost all women are treated with intravenous (IV) chemotherapy, delivered into a vein. Usually, this chemotherapy combines two or more drugs, as this seems to be more effective in stopping the growth of ovarian cancer than administering one drug alone. The standard approach is the combination of a platinum compound, such as cisplatin or carboplatin, and a taxane (a type of drug that blocks cell growth by stopping cell division), such as paclitaxel or docetaxel. Chemotherapy may vary, depending on the amount of tumor still remaining in the body after surgery. Bevacizumab, a treatment that affects blood supply to tumors, may be added to the treatment regimen. The typical course of chemotherapy involves three to six cycles (a cycle is a schedule of regular doses of a drug, followed by a rest period). Cycles vary depending on the drugs being used; ask your doctor about the schedule planned for your specific chemotherapy. In addition to receiving IV chemotherapy, women whose debulking surgery was optimal may also be offered intraperitoneal (IP) chemotherapy. This treatment delivers a concentrated dose of chemotherapy through a tube into the abdomen, directly to the cancer cells. IP chemotherapy works well, but the side effects may be more severe than with regular chemotherapy. Most women who have had debulking surgery followed by six cycles of chemotherapy go into complete remission. This is when the cancer seems to have disappeared from the body and no test currently available can detect any lingering cancer. CANCERCARE CONNECT TREATMENT UPDATE: OVARIAN CANCER 5

8 For women in complete remission, treatment may be stopped, or may be continued as consolidation or maintenance therapy, which is treatment given after cancer has disappeared following the initial therapy. The goal of consolidation or maintenance therapy is to maintain the remission, and delay or prevent a relapse. Bevacizumab or pazopanib may be used as consolidation or maintenance therapies. Women whose ovarian cancer does not go into remission or whose cancer returns less than six months after the first full course of chemotherapy are usually treated with other drugs. These medications include pegylated liposomal doxorubicin (PLD), topotecan, gemcitabine, and taxanes. If ovarian cancer returns more than six months after the first full course of chemotherapy, a woman may be retreated with carboplatin in combination with another drug such as paclitaxel, gemcitabine, or PLD. These women may also go on to clinical trials. 6

9 Targeted Treatments Targeted treatments are designed to target the specific cell mechanisms that are important for the growth and survival of tumor cells. In November 2014, the US Food and Drug Administration (FDA) approved the targeted treatment bevacizumab (Avastin) as a treatment for ovarian cancer. Bevacizumab works by preventing the growth of new blood vessels that feed tumors. Administered via intravenous infusion, bevacizumab is intended to be used in combination with chemotherapy in women who have advanced ovarian cancer that has come back after previous treatment. As noted, it may also be given as consolidation or maintenance therapy based on results of clinical trials. In December 2014, the FDA granted accelerated approval to olaparib (Lynparza), a new oral drug treatment (pill) for women with advanced ovarian cancer associated with defective BRCA genes, as detected by an FDA-approved test. Olaparib is a poly ADP-ribose polymerase (PARP) inhibitor that blocks enzymes involved in repairing damaged DNA. It is intended for women with previously treated ovarian cancer that is associated with defective BRCA genes. Radiation Radiation therapy uses high energy x-rays to kill cancer cells. Radiation is not used as the first treatment for ovarian cancer, but it may rarely be used if the cancer has recurred and is confined to a small area. CANCERCARE CONNECT TREATMENT UPDATE: OVARIAN CANCER 7

10 Treatment Approaches in Development There are many new approaches currently being tested for the treatment of ovarian cancer, including: Fighting platinum resistance. When the drugs cisplatin and carboplatin stop working, the cancer is said to be platinum resistant. Studies are looking for ways to make the cancer sensitive to these drugs again. Fosbretabulin, a vascular disrupting agent, has been approved for fast track status in platinum resistant ovarian cancer. Targeted therapy. Bevacizumab (Avastin) and olaparib (Lynparza) have been approved by the FDA for treatment of ovarian cancer in certain defined circumstances. Other targeted therapies being studied include pazopanib, vintafolide, niriparib, and additional drugs that inhibit PARPs (enzymes recently recognized as key regulators of cell survival and cell death). Immunotherapy. Immunotherapy is treatment that uses certain parts of the immune system to fight illnesses such as cancer. Immunotherapies being tested for ovarian cancer fall into six categories: monoclonal antibodies, checkpoint inhibitors and immune modulators, therapeutic vaccines, adoptive T-cell transfer, oncolytic viruses, and adjuvant immunotherapies. The testing is in early stages, but immunotherapy has been successfully used to treat other forms of cancer, and early studies show that they may prove useful in the treatment of ovarian cancer. 8

11 The Importance of Clinical Trials Clinical trials are the standard by which we measure the worth of new treatments and the quality of life of patients as they receive those treatments. For this reason, doctors and researchers urge people with cancer to take part in clinical trials. Your doctor can guide you in making a decision about whether a clinical trial is right for you. Here are a few things that you should know: Often, people who take part in clinical trials gain access to and benefit from new treatments. Before you participate in a clinical trial, you will be fully informed as to the risks and benefits of the trial. Most clinical trials are designed to test a new treatment against a standard treatment to find out whether the new treatment has any added benefit. You can stop taking part in a clinical trial at any time for any reason. Managing Treatment Side Effects All cancer treatments can cause side effects. It s important that you report any side effects you experience to your health care team so they can help you manage them. Report them right away don t wait for your next appointment. Doing so will improve your quality of life and allow you to stick with your treatment plan. It s important to remember that not all patients experience all side effects, and patients may experience side effects not listed in this booklet. CANCERCARE CONNECT TREATMENT UPDATE: OVARIAN CANCER 9

12 Ovarian cancer treatments can lead to early menopause, changes in sex drive (libido), and altered body image. As part of your treatment discussions with your doctor, ask about the issues that are of concern to you and how your surgery or medications may affect you. Concerns about fertility should be discussed before you start treatment for ovarian cancer. Your doctor can help you seek fertility counseling and planning. Side Effects of Chemotherapy The side effects of chemotherapy depend on the type and dose of drugs given and the length of time they are used, and can include: Hair loss Increased risk of infection (from having too few white blood cells) Easy bruising or bleeding Changes in memory or thinking Peripheral neuropathy (numbness or tingling in hands and feet) Mouth sores are also a side effect of chemotherapy. Your doctor may recommend treatments such as: Coating agents. These medications coat the entire lining of your mouth, forming a film to protect the sores and minimize pain. Topical painkillers. These are medications that can be applied directly to your mouth sores. Over-the-counter treatments. These include rinsing with baking soda or salt water, or magic mouthwash, a term given to a solution to treat mouth sores. Magic mouthwash usually contains at least three of these ingredients: 10

13 an antibiotic, an antihistamine or local anesthetic, an antifungal, a corticosteroid, and/or an antacid. Chemotherapy can cause changes in the way food and liquids taste, including causing an unpleasant metallic taste in the mouth. Many women find that switching to plastic utensils helps. It may also help to avoid eating or drinking anything that comes in a can, and to use enamel-coated pots and pans for food preparation. Managing Digestive Tract Symptoms Nausea and vomiting Avoid food with strong odors, as well as overly sweet, greasy, fried, or highly seasoned food. Eat meals cold or at room temperature, which often makes food more easily tolerated. Nibble on dry crackers or toast. These bland foods are easy on the stomach. Having something in your stomach when you take medication may help ease nausea. Diarrhea Drink plenty of water. Ask your doctor about using drinks such as Gatorade which provide electrolytes as well as liquid. Electrolytes are body salts that must stay in balance for cells to work properly. Over-the-counter medicines such as loperamide (Imodium A-D and others) and prescription drugs are available for diarrhea but should be used only if necessary. If the diarrhea is bad enough that you need medicine, discuss it with your doctor or nurse. Avoid sweetened foods and alcohol. CANCERCARE CONNECT TREATMENT UPDATE: OVARIAN CANCER 11

14 Choose fiber-dense foods such as whole grains, fruits and vegetables, all of which help form stools. Managing loss of appetite Because it s important to maintain your weight, eat small meals throughout the day. That s an easy way to take in more calories and protein. To keep from feeling full early, avoid liquids with meals or take only small sips (unless you need liquids to help swallow). Drink most of your liquids between meals. Be as physically active as you can. Sometimes, taking a short walk an hour or so before meals can help you feel hungry. Keep high-calorie, high-protein snacks on hand such as hard-boiled eggs, peanut butter, cheese, ice cream, granola bars, liquid nutritional supplements, puddings, nuts, canned tuna, or trail mix. Eat your favorite foods any time of the day. For example, if you like breakfast foods, eat them for dinner. Managing Fatigue Fatigue (extreme tiredness not helped by sleep) is one of the most common side effects of many cancer treatments. If you are taking a medication, your doctor may lower the dose of the drug, as long as it does not make the treatment less effective. If you are experiencing fatigue, talk to your doctor about whether taking a smaller dose is right for you. There are a number of other tips for reducing fatigue: Take several short naps or breaks. Take short walks or do some light exercise, if possible. Try easier or shorter versions of the activities you enjoy. 12

15 Ask your family or friends to help you with tasks you find difficult or tiring. Save your energy for things you find most important. Fatigue can be a symptom of other illnesses, such as diabetes, thyroid problems, heart disease, rheumatoid arthritis, and depression. So be sure to ask your doctor if he or she thinks any of these conditions may be contributing to your fatigue. Also, it could be very valuable to talk to an oncology social worker or oncology nurse. These professionals can also help you manage fatigue. They can work with you to manage any emotional or practical concerns that may be causing symptoms and help you find ways to cope. Managing Pain To help your doctor prescribe the best medication, it s useful to give an accurate report of your pain. Keep a journal that includes information on: When the pain occurs How long it lasts How strong it is on a scale of 1 to 10, with 1 being the least amount of pain and 10 the most intense What makes the pain feel better and what makes it feel more intense CANCERCARE CONNECT TREATMENT UPDATE: OVARIAN CANCER 13

16 The Importance of Treatment Summaries A treatment summary, sometimes called a shadow chart, is a document you create and which remains in your possession. Maintaining your own records allows you and your family members instant access to the specifics of your diagnosis and treatment. A treatment summary should include: Your name and date of birth. Date of diagnosis. Name, affiliation, and contact information of the doctor who gave the diagnosis. Prescribed therapy/therapies; including dates started and stopped, and dosages when appropriate. Dates and types of post-diagnosis testing, and the results. Other medication and supplements you are taking. Names, affiliations, and contact information of all members of your health care team. Talk to your doctor or a member of your health care team about your intention to create a treatment summary, and ask them what else they suggest be included. Take your treatment summary with you when you visit any doctor, not just your gynecologic oncologist. 14

17 Communicating with Your Health Care Team As you manage your ovarian cancer, it s important to remember that you are a consumer of health care. The best way to make decisions about health care is to educate yourself about your diagnosis and the members of your health care team, including nurses, social workers and patient navigators. In addition to creating a treatment summary, here are some tips for improving communication with your health care team: Start a health care journal. Having a health care journal or notebook will allow you to keep all of your health information in one place. You may want to write down the names and contact information of the members of your health care team, as well as any questions for your doctor. Keep a diary of your daily experiences with cancer and treatment. You can separate your journal or notebook into different sections to help keep it organized. Prepare a list of questions. Before your next medical appointment, write down your questions and concerns. Because your doctor may have limited time, you should ask your most important questions first, and be as specific and brief as possible. Bring someone with you to your appointments. Even if you have a journal and a prepared list of questions or concerns, it s always helpful to have support when you go to your appointments. The person who accompanies you can serve as a second set of ears. He or she may also think of questions to ask your doctor or remember details about your symptoms or treatment that you may have forgotten. CANCERCARE CONNECT TREATMENT UPDATE: OVARIAN CANCER 15

18 Write down your doctor s answers. Taking notes will help you remember your doctor s responses, advice and instructions. If you cannot write down the answers, ask the person who accompanies you to do that for you. If you have a mobile device, ask if you can use it to take notes. Writing notes will help you review the information later. Record your visit if your doctor allows it. Recording the conversation with your doctor gives you a chance to hear specific information again or share it with family members or friends. Incorporate other health care professionals into your team. Your gynecologic and medical oncologists are essential members of your health care team, but there are other health care professionals who can help you manage your diagnosis and treatment: Your primary care physician should be kept updated about your ovarian cancer treatment and any test results. Your local pharmacist is a great source of knowledge about the medications you are taking; have all of your prescriptions filled at the same pharmacy to avoid the possibility of harmful drug interactions. Make sure your oncologists know of any other medical conditions you have, or any pain you are experiencing, so that they can consult with your primary care physician or your specialist if needed. Because ovarian cancer can return after treatment, many women with this diagnosis find themselves coping with it over the long term. That s why it s especially important to maintain a relationship with your entire health care team. 16

19 Remember, there is no such thing as over-communication. Your health care team wants to know about how you re feeling overall, which includes your level of pain, your energy level, your appetite, and your mood and spirits. CancerCare s Free Support Services and Programs Receiving a diagnosis of ovarian cancer can be very difficult, and adjusting to the necessary changes in your life can be challenging. CancerCare can help. We are a national nonprofit organization providing free, professional services to anyone affected by cancer. Our licensed oncology social workers can provide support and education, help in navigating the complicated health care system, and provide information on support groups and other resources. To learn more about how CancerCare helps, call us at HOPE (4673) or visit You will likely also build your own personal support network, comprised of family and friends. In doing so, it s best to take some time to think about the people in your life and how they are best suited to help. Match the task to their strengths ask a family member who loves to shop to pick up something for you at the store; ask a friend who s a good listener to come over for a chat. CANCERCARE CONNECT TREATMENT UPDATE: OVARIAN CANCER 17

20 MORE ABOUT OVARIAN CANCER Frequently Asked Questions Q. I ve just finished chemotherapy for ovarian cancer. I have many symptoms of recurrence, but all my tests came back negative. How can this be? A. There are several possible reasons why some women have symptoms of recurrence despite normal scan and blood test results. One is that the original tumor, or the treatments for it, caused scar tissue to form or that some other physical problem is causing symptoms. Changes in the lower digestive tract, which many women experience after surgery, could also cause symptoms. It s also possible that a cancer recurrence won t show up on scans and blood tests. Often, the cancer comes back in the form of very small tumors that may not appear on tests. Talk with your doctor about any symptoms you are experiencing; he or she may want to do additional testing. Q. I was recently diagnosed with ovarian cancer, and I have large tumors in my abdominal cavity. Before the surgery, my oncologist wants me to have chemotherapy to shrink the tumors. Is this a common practice? A. Chemotherapy delivered before surgery known as neoadjuvant chemotherapy can be an option for some women, including those whose tumors are likely to be difficult to remove and those who may not be able to physically withstand surgery. It s always best to consult a gynecologic 18

21 oncologist who can confirm what the best option is for you whether to have surgery first or chemotherapy first. Most women who undergo neoadjuvant chemotherapy still benefit from at least one attempt to have a tumor removed surgically. Q. A. Is the drug metformin a treatment for ovarian cancer? Metformin is used to treat people with Type 2 diabetes. There have been some observational studies that women with ovarian cancer who take metformin for their diabetes seem to do better than those not on metformin. However, there is currently no known therapeutic strategy for treating ovarian cancer that includes the use of metformin. Q. I ve been diagnosed with ovarian cancer. Because it s a reproductive cancer, should I avoid foods high in estrogen? A. Foods high in estrogen include tofu, tempeh, soy milk, soybeans, dried fruits, peas, and bran cereals. There is no evidence that these foods increase the risk or treatment of ovarian cancer if eaten in moderation as part of a healthy diet. Excessive amounts of these and other estrogenrich foods should be avoided, and estrogen supplements should not be taken. Q. A. Why do some treatments work for some women with ovarian cancer but not for others? This is most likely due to differences in the genetic makeup of each woman s tumor. In recent years, scientists have learned that the tumors of people with the same type and stage of cancer can have different genetic CANCERCARE CONNECT TREATMENT UPDATE: OVARIAN CANCER 19

22 characteristics that may affect how they respond to treatment. In some cases, having an understanding of a tumor s genetic makeup is helping doctors better select treatments that are more likely to work. The hope is that we will someday be able to identify all of the differences responsible for each tumor in order to treat them more effectively. Q. A. My doctor suggested I see a genetic counselor. Why? Genetic counseling can help women make informed decisions about genetic testing. In a genetic counseling session for ovarian cancer, the counselor will typically collect a detailed family and medical history and discuss genetic mutations, such as those in BRCA1 and BRCA2 genes, which can increase the chance of developing ovarian cancer. 20

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